Angiopoietin-Based Interventions for Treating Cerebral Malaria

ABSTRACT

The present invention provides methods for treating, preventing or reducing the severity of cerebral malaria. The methods of the present invention comprise administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising a modified angiopoietin molecule such as AngF1-Fc-F1.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a division of U.S. application Ser. No. 15/949,472,filed Apr. 10, 2018, which is a division of U.S. application Ser. No.15/414,925, filed Jan. 25, 2017, now U.S. Pat. No. 9,968,653, which is adivision of U.S. application Ser. No. 14/529,677, filed Oct. 31, 2014,now U.S. Pat. No. 9,592,271, which claims the benefit under 35 USC §119(e) of U.S. Provisional Application No. 61/898,539, filed on Nov. 1,2013, and 62/040,514, filed on Aug. 22, 2014, the disclosures of whichare each herein incorporated by reference in their entireties.

SEQUENCE LISTING

This application includes an electronic sequence listing in a file named“A0007US04-Sequence.txt”, created on Feb. 21, 2019 and containing 16,640bytes, which is hereby incorporated by reference in its entirety for allpurposes.

FIELD OF THE INVENTION

The present invention relates to the use of angiopoietin molecules orvariants thereof to treat or prevent cerebral malaria in a subject inneed thereof.

BACKGROUND

Cerebral malaria is a major cause of global morbidity and mortality,typically characterized by loss of blood brain barrier integrity andneurological impairment, followed by death in 15-30% cases despitetreatment. Cerebral malaria in humans is caused by Plasmodiumfalciparum. The typical symptoms of cerebral malaria include fever,headache and myalgia followed by drowsiness, confusion, impaired balanceor coordination, motor impairment, coma and death. Treatment options arecurrently limited to quinine or artemisinin derivatives, which controlparasitemia but are not as effective in reducing mortality. Accordingly,an unmet need exists in the art for effective therapeutic and preventiveapproaches without adverse side-effects that prevent or treat cerebralmalaria.

BRIEF SUMMARY OF THE INVENTION

According to one aspect of the present invention, methods are providedfor treating, preventing or ameliorating at least one symptom,indication or complication of cerebral malaria (including, e.g.,experimental cerebral malaria, falciparum malaria, etc.) in a subject.The methods according to this aspect of the invention compriseadministering a therapeutically effective amount of a pharmaceuticalcomposition comprising an angiopoietin or modified angiopoietin proteinor a fragment thereof to a subject in need thereof.

In certain embodiments, the at least one symptom, indication orcomplication is selected from the group consisting of fever, headacheand myalgia followed by drowsiness, confusion, vascular leakage, loss ofblood-brain barrier integrity, elevated blood level of an endothelialmarker, sequestration of parasitized erythrocytes in the brain, impairedbalance or coordination, motor impairment, splenomegaly, loss ofreflexes and self-preservation, lack of hygiene-related behavior, acutelung injury, convulsion, coma and death. In certain embodiments, theendothelial marker is selected from the group consisting ofangiopoietin-1 (Ang1), angiopoietin-2 (Ang2), angiopoietin receptorTie2, von Willebrand Factor (vWF), intercellular adhesion molecule-1(ICAM-1), IP-10, E-selectin and vascular cell adhesion molecule-1(VCAM-1).

According to another aspect of the present invention, methods areprovided for improving or increasing survival of a subject followingPlasmodium infection. The methods comprise administering atherapeutically effective amount of a pharmaceutical compositioncomprising an angiopoietin or modified angiopoietin protein or afragment thereof to the subject in need thereof. In a related aspect,the invention provides methods for preventing vascular leakage orprotecting blood brain barrier integrity, the method comprisingadministering a pharmaceutical composition comprising a therapeuticallyeffective amount of an modified angiopoietin protein or a fragmentthereof to a subject in need thereof.

In another aspect, the invention provides for methods for preventingsevere cerebral malaria in a subject infected with Plasmodium spp., themethod comprising selecting a subject with more than 0.1% parasitemia;and administering a pharmaceutical composition comprising atherapeutically effective amount of an modified angiopoietin protein ora fragment thereof to the subject in need thereof.

In certain embodiments, the administration of the modified angiopoietinto a subject in need thereof prevents at least one indication ofneurological impairment selected from the group consisting of impairedbalance or coordination, motor impairment, loss of reflexes andself-preservation, long term neurocognitive injury and impairmentincluding memory deficits and affective disorders, lack ofhygiene-related behavior, convulsion, and fitting or seizures.

In certain embodiments, the modified angiopoietin is administered incombination with a second therapeutic agent or therapy. In certainembodiments, the modified angiopoietin is administered as adjunctivetherapy along with a second therapeutic agent such as e.g., artesunate.

Exemplary angiopoietin molecules that can be used in the context of themethods of the present invention include, e.g., angiopoietin-1,recombinant angiopoietin (e.g., angiopoietin-1 expressed in adenoviralvector), and a modified angiopoietin (e.g., a fusion protein comprisingan angiopoietin or a fragment thereof). According to certainembodiments, the modified angiopoietin is a fusion protein consisting ofthe fibrinogen-like domain of angiopoietin fused to the Fc fragment ofhuman IgG1 and then forced into a tetramer (Davis et al 2003, Nat.Struct. Biol. 10: 38-44). In certain embodiments, the modifiedangiopoietin comprises a fusion protein comprising a firstfibrinogen-like domain of angiopoietin fused at its C-terminal end tothe N-terminal end of an Fc fragment and the Fc fragment fused at itsC-terminal end to the N-terminal end of a second fibrinogen-like domainof angiopoietin.

One such type of modified angiopoietin that can be used in the contextof the methods of the present invention is AngF1-Fc-F1 (SEQ ID NO: 2).

In certain embodiments, the present invention provides use of anangiopoietin or a modified angiopoietin protein or a fragment thereof ofthe invention in the manufacture of a medicament to treat or inhibit orprevent cerebral malaria in a subject, including humans.

In another aspect, the present invention includes methods for treating,preventing or ameliorating at least one symptom, indication orcomplication of cerebral malaria (including, e.g., experimental cerebralmalaria, falciparum malaria, etc.) in a subject. The methods accordingto this aspect of the invention comprise administering a therapeuticallyeffective amount of a pharmaceutical composition comprising an anti-Tie2antibody or an antigen-binding fragment thereof to a subject in needthereof. In certain embodiments, the anti-Tie2 antibody is an activatingor agonist antibody.

Other embodiments of the present invention will become apparent from areview of the ensuing detailed description.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 shows the survival curves of C57Bl/6 (Experimental CerebralMalaria-Susceptible; ECM-S) and BALB/c (Experimental CerebralMalaria-Resistant; ECM-R) mice infected with Plasmodium berghei ANKA(PbA).

FIG. 2 shows the percent fold change in Rapid Murine Coma and BehavioralScore (RMCBS) in ECM-S and ECM-R mice infected with PbA.

FIG. 3 shows comparative levels of Evans Blue dye extracted from thebrains of ECM-R and ECM-S mice infected with PbA.

FIG. 4 shows percent parasitemia in ECM-S and ECM-R mice infected withPbA.

FIG. 5 shows Ang-1 serum levels over the course of PbA infection.***p<0.0001 (time), *p<0.05 (strain) and **p<0.001 (2-way ANOVA withBonferroni post-test for the indicated comparison).

FIGS. 6(a) and 6(b): FIG. 6(a) RMCBS (%) and serum Ang-1 levels (ng/ml)*p<0.05 compared to naïve, One-way ANOVA. FIG. 6(b) depicts scatterplots showing linear regression analysis between serum Ang1 (ng/ml)levels and time to death (hours) (Spearman correlation, r value,p<0.0001).

FIG. 7 shows relative Ang2 protein levels in ECM-R and ECM-S mice postPbA infection.

FIG. 8 shows vWF protein levels in ECM-R and ECM-S mice on Day 6 postinfection with PbA.

FIG. 9 shows the relative Tie2 mRNA levels in ECM-R and ECM-S mice postPbA infection.

FIG. 10 shows the survival curves of C57Bl/6 mice infected with PbA andtreated with anti-Ang2 antibody (mAb isotype control (mAb ‘A’) orsaline.

FIG. 11 shows percent fold change in RMCBS in C57Bl/6 mice infected withPbA and treated with anti-Ang2 antibody (mAb isotype control (mAb ‘A’)or saline.

FIG. 12 shows percent parasitemia on Day 7 post PbA infection in C57Bl/6mice treated with anti-Ang2 antibody (mAb isotype control (mAb ‘A’) orsaline.

FIGS. 13(a) and 13(b) show the plasma protein levels of (FIG. 13(a)) vWFand (FIG. 13(b)) E-selectin, ICAM and VCAM in naïve C57Bl/6 mice(hatched bars) or mice infected with PbA and treated with anti-Ang2antibody (mAb ‘B’) (grey bars) or isotype control (mAb ‘A’) (blackbars).

FIG. 14 shows survival curves of C57Bl/6 mice infected with PbA andtreated with AngF1-Fc-F1, Fc control, anti-Ang2 antibody, a dualAnti-Ang1/Ang2 antibody (“comparator”) or saline.

FIG. 15 shows percent parasitemia in C57Bl/6 mice infected with PbA andtreated with AngF1-Fc-F1, Fc control, anti-Ang2 antibody, a dualAnti-Ang1/Ang2 antibody (“comparator”) or saline.

FIGS. 16(a) and 16(b): FIG. 16(a) shows levels of Evans Blue dyeextracted from the brains of C57Bl/6 mice infected with PbA and treatedwith Fc control (A), anti-Ang2 antibody (B), AngF1-Fc-F1 (C), oranti-Ang1/Ang2 comparator antibody (D). FIG. 16(b) shows the percentparasitemia in C57Bl/6 mice infected with PbA and treated with Fccontrol (A), anti-Ang2 antibody (B), AngF1-Fc-F1 (C), or anti-Ang1/Ang2“comparator” antibody (D).

FIGS. 17(a) and 17(b): FIG. 17(a) shows the percent change in RMCBS onDay 6 post PbA infection in C57Bl/6 mice treated with AngF1-Fc-F1 orisotype control. FIG. 17(b) shows the percent change over 7 days inRMCBS in C57Bl/6 mice infected with PbA and treated with AngF1-Fc-F1 orisotype control.

FIGS. 18(a) and 18(b): FIG. 18(a) shows percent parasitemia in C57Bl/6mice infected with PbA and treated with AngF1-Fc-F1 or isotype control.FIG. 18(b) shows the percent fold change in weight of C57Bl/6 miceinfected with PbA and treated with AngF1-Fc-F1 or isotype control.

FIGS. 19(a), 19(b) and 19(c): FIG. 19 shows plasma protein levels ofcytokines TNFα and IFNγ (a), vWF (b), E-selectin, sICAM and VCAM-1 (c)of naïve C57Bl/6 mice and mice infected with PbA and treated withAngF1-Fc-F1 or Fc control.

FIG. 20 shows survival curves of C57Bl/6 mice infected with PbA andtreated with artesunate+AngF1-Fc-F1, artesunate+saline, or saline.

FIGS. 21(a) and 21(b): FIG. 21(a) shows percent parasitemia in C57Bl/6mice infected with PbA and treated with artesunate+AngF1-Fc-F1 orartesunate+saline. FIG. 21(b) shows the percent fold change in weight ofC57Bl/6 mice infected with PbA and treated with artesunate+AngF1-Fc-F1or artesunate+saline.

DETAILED DESCRIPTION

Before the present invention is described, it is to be understood thatthis invention is not limited to particular methods and experimentalconditions described, as such methods and conditions may vary. It isalso to be understood that the terminology used herein is for thepurpose of describing particular embodiments only, and is not intendedto be limiting, since the scope of the present invention will be limitedonly by the appended claims.

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. As used herein, the term“about,” when used in reference to a particular recited numerical value,means that the value may vary from the recited value by no more than 1%.For example, as used herein, the expression “about 100” includes 99 and101 and all values in between (e.g., 99.1, 99.2, 99.3, 99.4, etc.).

Although any methods and materials similar or equivalent to thosedescribed herein can be used in the practice of the present invention,the preferred methods and materials are now described. All publicationsmentioned herein are incorporated herein by reference to describe intheir entirety.

Methods for Treating, Preventing or Ameliorating Cerebral Malaria

Cerebral malaria pathogenesis is associated with endothelial activationand loss of blood brain barrier integrity. The angiopoietin-Tie2signaling pathway is a key regulator of endothelial function.Alterations in the angiogenic balance, specifically increasedangiopoietin-2 (Ang2) relative to Ang1, has been associated with poorclinical outcome in cerebral malaria (Yeo et al, 2008 PNAS; Lovegrove etal PLoS ONE 2009; Erdman et al PLoS ONE 2011; Conroy et al PLoS ONE2011). However, it is unclear whether the Ang-Tie2 pathway is causallyinvolved in cerebral malaria pathogenesis. The inventors havehypothesized that dysregulation in angiopoietins contributes to cerebralmalaria pathogenesis, and therefore, interventions to maintain Tie2activation may promote endothelial stability, prevent deleteriouseffects to the blood brain barrier and improve outcome followingPlasmodium infection. Accordingly, it is shown herein, that modifiedangiopoietins, when administered to an infected subject, protect theblood brain barrier integrity and prevent neurological impairment anddeath. As disclosed elsewhere herein, the inventors have used awell-known murine model of Plasmodium berghei ANKA (PbA)—inducedexperimental cerebral malaria (ECM) to study alterations inangiopoietins associated with disease severity and fatality and to showthat dysregulation of the Ang/Tie2 axis is associated with diseaseseverity and fatality. As shown herein, Ang1 levels inversely correlatedwith morbidity and mortality in the mouse model of cerebral malaria.Based on the studies shown herein, it is established that Ang1 isnecessary to maintain blood brain barrier integrity in response to alethal malaria challenge and can improve survival above that achieved byconventional treatment (e.g., artesunate) alone. Further, administrationof a modified angiopoietin enhanced blood brain barrier integrity andpromoted maintenance of a quiescent endothelium via down-regulation ofpro-adhesive molecules implicated in parasite sequestration and cerebralmalaria pathogenesis.

Accordingly, the present invention includes methods for treating,preventing, or ameliorating at least one symptom, indication orcomplication of cerebral malaria (including, for example, experimentalcerebral malaria, falciparum malaria, etc.) in a subject. The methodsaccording to this aspect of the invention comprise administering atherapeutically effective amount of a pharmaceutical compositioncomprising a modified angiopoietin protein or a fragment thereof to thesubject in need thereof.

“Cerebral malaria” (CM), as used herein, means an infectious diseasecaused by Plasmodium species and characterized by loss of blood brainbarrier integrity and neurological impairment. The symptoms of CMinclude, but are not limited to, fever, headache and myalgia followed bydrowsiness, confusion, vascular leakage, loss of blood-brain barrierintegrity, elevated blood level of an endothelial marker, sequestrationof parasitized erythrocytes in the brain, impaired balance orcoordination, motor impairment, splenomegaly, loss of reflexes andself-preservation, lack of hygiene-related behavior, acute lung injury,convulsion, fitting, coma and death. The clinicopathology of CM ischaracterized by sequestration of infected red blood cells in thevenules and capillaries of the brain followed by endothelial activation.The term “cerebral malaria” includes but is not limited to severecerebral malaria caused in humans by Plasmodium falciparum, andexperimental cerebral malaria (ECM), caused in mice by Plasmodiumberghei ANKA.

As used herein, the terms “treat”, “treating”, or the like, mean toalleviate a symptom or a complication, eliminate the causation of asymptom or a complication either on a temporary or permanent basis, orto prevent or slow the appearance of a symptom or complication ofcerebral malaria in the subject. In the context of the presentinvention, the terms “treat”, “treating”, or the like, refer to reducingor decreasing mortality in a subject infected with Plasmodium species.The terms also refer to preventing the loss of blood brain barrierintegrity and neurological impairment in a subject with cerebralmalaria. In certain embodiments, the present methods are useful fortreating or ameliorating at least one symptom, indication orcomplication of cerebral malaria including, but not limited to, fever,headache and myalgia followed by drowsiness, confusion, vascularleakage, loss of blood-brain barrier integrity, elevated blood level ofan endothelial marker, sequestration of parasitized erythrocytes in thebrain, impaired balance or coordination, motor impairment, splenomegaly,loss of reflexes and self-preservation, lack of hygiene-relatedbehavior, acute lung injury, convulsion, fitting, coma and death.

By the phrase “therapeutically effective amount” is meant an amount thatproduces the desired effect for which it is administered. The exactamount will depend on the purpose of the treatment, and will beascertainable by one skilled in the art using known techniques (see, forexample, Lloyd (1999) The Art, Science and Technology of PharmaceuticalCompounding).

As used herein, the term “subject” refers to an animal, preferably amammal, that exhibits one or more symptoms, indications or complicationsof cerebral malaria, and/or who has been diagnosed with cerebral malaria(CM) and/or in need of amelioration, prevention and/or treatment ofcerebral malaria. The term “a subject in need thereof” may also include,e.g., subjects who, prior to treatment, exhibit (or have exhibited) oneor more symptoms or indications of cerebral malaria such as, e.g.,fever, headache and myalgia followed by drowsiness, confusion, vascularleakage, loss of blood-brain barrier integrity, elevated blood level ofan endothelial marker, sequestration of parasitized erythrocytes in thebrain, impaired balance or coordination, motor impairment, splenomegaly,loss of reflexes and self-preservation, lack of hygiene-relatedbehavior, acute lung injury, convulsion, fitting, coma and death.

In the context of the present invention, “a subject in need thereof” mayinclude a subset of population, which may show an elevated level of anendothelial marker. Such a subject population may show an elevated levelof an endothelial marker such as, e.g., Ang1, Ang2, Tie2, vWF, ICAM-1,E-selectin and VCAM-1.

The methods of the present invention may be used to treat cerebralmalaria in adults, including the elderly. In some embodiments, themethods of the present invention are used to treat adults more than 50years, more than 55 years, more than 60 years, more than 65 years, ormore than 70 years old.

In some embodiments, the methods herein may be used to treat cerebralmalaria in children who are ≥3 years old. For example, the presentmethods may be used to treat infants who are less than 1 month, 2months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9months, 10 months, 11 months or less than 12 months old. In otherembodiments, the methods of the present invention may be used to treatchildren who are more than 3 years old, more than 4 years, 5 years, 6years, 7 years, 8 years, 9 years, 10 years, 11 years, 12 years, 13years, 14 years, or more than 15 years old.

The present invention also includes methods for increasing survival in asubject with cerebral malaria. The methods according to this aspect ofthe invention comprise administering to the subject one or more doses ofa pharmaceutical composition comprising a modified angiopoietin toincrease survival in the subject.

The present invention also includes methods to prevent severe cerebralmalaria in a subject infected with Plasmodium species, the methodscomprising administering a therapeutically effective amount of apharmaceutical composition comprising a modified angiopoietin to thesubject in need thereof. In certain embodiments, the modifiedangiopoietin is administered as an exogenous protein.

The term “preventing” as used herein refers to preventing development ofdisease. The term, as used herein, also includes preventing vascularleakage, protecting blood brain barrier integrity and the onset ofneurological symptoms such as seizures and paralysis upon infection withthe pathogen. In some embodiments, the term refers to preventingendothelial dysfunction, which is a key pathological feature of cerebralmalaria (including experimental cerebral malaria).

The present invention includes methods for treating, preventing orreducing the severity of cerebral malaria comprising administering atherapeutically effective amount of a pharmaceutical compositioncomprising a modified angiopoietin to a subject in need thereof, whereinthe pharmaceutical composition is administered to the subject inmultiple doses, e.g., as part of a specific therapeutic dosing regimen.For example, the therapeutic dosing regimen may comprise administeringmultiple doses of the pharmaceutical composition to the subject at afrequency of about once a day, once every two days, once every threedays, once every four days, once every five days, once every six days,once a week, once every two weeks, once every three weeks, once everyfour weeks, once a month, once every two months, once every threemonths, once every four months, or less frequently. In some embodiments,the therapeutic dosing regimen comprises administering multiple doses ofthe pharmaceutical composition to the subject at a frequency of aboutonce a day, about 2 times a day, about 3 times a day or more than 4times a day.

In certain embodiments, the modified angiopoietin is administeredsubcutaneously, intravenously, intracranially, intraventricularly, ordelivered systemically in an adenoviral vector to a subject in needthereof.

The methods of the present invention, according to certain embodiments,comprise administering to a subject a therapeutically effective amountof a pharmaceutical composition comprising a modified angiopoietin incombination with a second therapeutic agent. The second therapeuticagent may be an agent selected from the group consisting of anartemisinin, quinine, or a variant or derivative thereof (e.g.,artesunate), a vascular endothelial growth factor (VEGF) antagonist[e.g., a “VEGF-Trap” such as aflibercept or other VEGF-inhibiting fusionprotein as set forth in U.S. Pat. No. 7,087,411, or an anti-VEGFantibody or antigen binding fragment thereof (e.g., bevacizumab, orranibizumab)], an activating anti-Tie2 antibody, an Ang2 antagonist, anantihistamine, and a non-steroidal anti-inflammatory drug (NSAID). Asused herein, the phrase ‘in combination with” means that thepharmaceutical composition comprising a modified angiopoietin isadministered to the subject at the same time as, just before, or justafter administration of the second therapeutic agent. In certainembodiments, the second therapeutic agent is administered as aco-formulation with the modified angiopoietin.

The present invention also includes methods for treating, preventing orameliorating at least one symptom, indication or complication ofcerebral malaria in a subject, wherein the methods compriseadministering a therapeutically effective amount of a pharmaceuticalcomposition comprising an anti-Tie2 antibody or an antigen-bindingfragment thereof to the subject in need thereof. In certain embodiments,the anti-Tie2 antibody is an activating or agonist antibody, e.g., theantibody upon binding to Tie2 increases the activity of Tie2 orotherwise stimulates Tie2 signaling. In certain embodiments, theanti-Tie2 antibody is an antibody as set forth in US20130209492. Theanti-Tie2 antibody may be administered subcutaneously, intravenously, orintracranially at a dosage of from about 0.1 mg/kg to about 100 mg/kg ofthe subject's body weight. In certain embodiments, the activatinganti-Tie2 antibody is administered in combination with a secondactivating anti-Tie2 antibody to the subject in need thereof.

In another aspect, the present invention includes methods for treating,preventing or ameliorating at least one symptom, indication orcomplication of a disease or disorder associated with dysfunction of theAng-Tie2 pathway in a subject. The methods comprise administering atherapeutically effective amount of a pharmaceutical compositioncomprising a modified angiopoietin protein or a fragment thereof to thesubject in need thereof. In certain embodiments, the angiopoietin orvariants thereof may be used to treat, prevent or ameliorate at leastone symptom or indication of a disease or disorder including cerebralmalaria, sepsis, anthrax, dengue, hemorrhagic fever (including viralhemorrhagic fever, e.g., lassa fever, Yellow fever, and Ebola fever),toxic shock syndrome, HUS, hemorrhagic shock (model for massive bloodloss due to traumatic injury, e.g., IED), ischemic reperfusion,hemolytic uremic syndrome, myocardial infarction and stroke.

Modified Angiopoietins

The methods of the present invention comprise administering to a subjectin need thereof a therapeutic composition comprising an angiopoietin ora variant thereof. As used herein, an “angiopoietin” includesangiopoietin-1 (Ang1) or angiopoietin-2 (Ang2).

Non-limiting examples of categories of modified angiopoietins includerecombinant angiopoietins (e.g., angiopoietin expressed in an adenoviralvector; Thurston et al 2000, Nat. Med.), mutant and chimeric forms ofangiopoietins, and fusion proteins comprising angiopoietin or a fragmentthereof that specifically bind Tie1 and/or Tie2 receptors.

According to certain exemplary embodiments of the present invention, themodified angiopoietin is a fusion protein comprising one or more domainsof the angiopoietin molecule fused to a multimerizing domain. In generalterms, the multimerizing domain(s) of the present invention function toconnect the various components of the angiopoietin molecule (e.g., thefibrinogen-like domains) with one another. As used herein, a“multimerizing domain” is any macromolecule that has the ability toassociate (covalently or non-covalently) with a second macromolecule ofthe same or similar structure or constitution. For example, amultimerizing domain may be a polypeptide comprising an immunoglobulinC_(H)3 domain. A non-limiting example of a multimerizing domain is an Fcportion of an immunoglobulin, e.g., an Fc domain of an IgG selected fromthe isotypes IgG1, IgG2, IgG3, and IgG4, as well as any allotype withineach isotype group. In certain embodiments, the multimerizing domain isan Fc fragment or an amino acid sequence of 1 to about 200 amino acidsin length containing at least one cysteine residues. In otherembodiments, the multimerizing domain is a cysteine residue or a shortcysteine-containing peptide. Other multimerizing domains includepeptides or polypeptides comprising or consisting of a leucine zipper, ahelix-loop motif, or a coiled-coil motif.

In certain embodiments, the modified angiopoietin is a fusion proteincomprising one or more fibrinogen-like domains of the angiopoietin-1molecule fused to the Fc fragment of an immunoglobulin comprising any ofthe amino acid sequences, as set forth in U.S. Pat. No. 7,008,781. Incertain exemplary embodiments, the fusion protein that can be used inthe context of the methods of the present invention comprises a firstfibrinogen-like domain of angiopoietin fused at its C-terminal end tothe N-terminal end of an IgG Fc fragment and the C-terminal of the Fcfragment fused to the N-terminal end of a second fibrinogen-like domainof angiopoietin (Davis et al, Nat. Struct. Biol. 2003), wherein theangiopoietin may be Ang1 or Ang2. According to certain exemplaryembodiments, the methods of the present invention comprise the use ofthe modified angiopoietin referred to and known in the art asAngF1-Fc-F1. In certain embodiments, the modified angiopoietin is adimer comprising two AngF1-Fc-F1s that associate through intramolecularassociation of the Fc fragments (also referred to as BowAng1, asdisclosed in Davis et al, Nat. Struct. Biol. 2003). According to certainembodiments, the fusion protein comprises the amino acid sequence of SEQID NO: 2. In some embodiments, the fusion protein comprises the aminoacid sequence of SEQ ID NO: 4.

Other modified angiopoietins that can be used in the context of themethods of the present invention include any of the modifiedangiopoietin molecules as set forth in U.S. Pat. Nos. 6,265,564,6,441,137, and 6,825,008.

In certain embodiments, the angiopoietin or variants thereof may be usedto treat, prevent or ameliorate at least one symptom or indication of adisease or disorder including sepsis, dengue, hemorrhagic fever(including viral hemorrhagic fever, e.g., lassa fever, Yellow fever, andEbola fever), toxic shock syndrome, HUS, hemorrhagic shock (model formassive blood loss due to traumatic injury, e.g., IED), ischemicrepurfusion, hemolytic uremic syndrome, myocardial infarction andstroke.

Pharmaceutical Compositions

The present invention includes methods which comprise administering amodified angiopoietin to a subject wherein the modified angiopoietin iscontained within a pharmaceutical composition. The pharmaceuticalcompositions of the invention may be formulated with suitable carriers,excipients, and other agents that provide suitable transfer, delivery,tolerance, and the like. A multitude of appropriate formulations can befound in the formulary known to all pharmaceutical chemists: Remington'sPharmaceutical Sciences, Mack Publishing Company, Easton, Pa. Theseformulations include, for example, powders, pastes, ointments, jellies,waxes, oils, lipids, lipid (cationic or anionic) containing vesicles(such as LIPOFECTIN™), DNA conjugates, anhydrous absorption pastes,oil-in-water and water-in-oil emulsions, emulsions carbowax(polyethylene glycols of various molecular weights), semi-solid gels,and semi-solid mixtures containing carbowax. See also Powell et al.“Compendium of excipients for parenteral formulations” PDA (1998) JPharm Sci Technol 52:238-311.

Various delivery systems are known and can be used to administer thepharmaceutical composition of the invention, e.g., encapsulation inliposomes, microparticles, microcapsules, recombinant cells capable ofexpressing the mutant viruses, receptor mediated endocytosis (see, e.g.,Wu et al., 1987, J. Biol. Chem. 262: 4429-4432). Methods ofadministration include, but are not limited to, intradermal,intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal,epidural, and oral routes. The composition may be administered by anyconvenient route, for example by infusion or bolus injection, byabsorption through epithelial or mucocutaneous linings (e.g., oralmucosa, rectal and intestinal mucosa, etc.) and may be administeredtogether with other biologically active agents.

A pharmaceutical composition of the present invention can be deliveredsubcutaneously or intravenously with a standard needle and syringe. Inaddition, with respect to subcutaneous delivery, a pen delivery devicereadily has applications in delivering a pharmaceutical composition ofthe present invention. Such a pen delivery device can be reusable ordisposable. A reusable pen delivery device generally utilizes areplaceable cartridge that contains a pharmaceutical composition. Onceall of the pharmaceutical composition within the cartridge has beenadministered and the cartridge is empty, the empty cartridge can readilybe discarded and replaced with a new cartridge that contains thepharmaceutical composition. The pen delivery device can then be reused.In a disposable pen delivery device, there is no replaceable cartridge.Rather, the disposable pen delivery device comes prefilled with thepharmaceutical composition held in a reservoir within the device. Oncethe reservoir is emptied of the pharmaceutical composition, the entiredevice is discarded.

In certain situations, the pharmaceutical composition can be deliveredin a controlled release system. In one embodiment, a pump may be used.In another embodiment, polymeric materials can be used; see, MedicalApplications of Controlled Release, Langer and Wise (eds.), 1974, CRCPres., Boca Raton, Fla. In yet another embodiment, a controlled releasesystem can be placed in proximity of the composition's target, thusrequiring only a fraction of the systemic dose (see, e.g., Goodson,1984, in Medical Applications of Controlled Release, supra, vol. 2, pp.115-138). Other controlled release systems are discussed in the reviewby Langer, 1990, Science 249:1527-1533.

The injectable preparations may include dosage forms for intravenous,subcutaneous, intracutaneous and intramuscular injections, dripinfusions, etc. These injectable preparations may be prepared by knownmethods. For example, the injectable preparations may be prepared, e.g.,by dissolving, suspending or emulsifying the antibody or its saltdescribed above in a sterile aqueous medium or an oily mediumconventionally used for injections. As the aqueous medium forinjections, there are, for example, physiological saline, an isotonicsolution containing glucose and other auxiliary agents, etc., which maybe used in combination with an appropriate solubilizing agent such as analcohol (e.g., ethanol), a polyalcohol (e.g., propylene glycol,polyethylene glycol), a nonionic surfactant [e.g., polysorbate 80,HCO-50 (polyoxyethylene (50 mol) adduct of hydrogenated castor oil)],etc. As the oily medium, there are employed, e.g., sesame oil, soybeanoil, etc., which may be used in combination with a solubilizing agentsuch as benzyl benzoate, benzyl alcohol, etc. The injection thusprepared is preferably filled in an appropriate ampoule.

Advantageously, the pharmaceutical compositions for oral or parenteraluse described above are prepared into dosage forms in a unit dose suitedto fit a dose of the active ingredients. Such dosage forms in a unitdose include, for example, tablets, pills, capsules, injections(ampoules), suppositories, etc.

Dosage

The amount of the modified angiopoietin (e.g., AngF1-Fc-F1) administeredto a subject according to the methods of the present invention is,generally, a therapeutically effective amount. As used herein, thephrase “therapeutically effective amount” means an amount of modifiedangiopoietin that results in one or more of: (a) a reduction in theseverity or duration of a symptom, indication or complication of severecerebral malaria; (b) increased survival; (c) protection of the bloodbrain barrier integrity; and (d) prevention of neurological impairmentin the subject.

In the case of a modified angiopoietin, a therapeutically effectiveamount can be from about 0.05 mg to about 600 mg, e.g., about 0.05 mg,about 0.1 mg, about 1.0 mg, about 1.5 mg, about 2.0 mg, about 10 mg,about 20 mg, about 30 mg, about 40 mg, about 50 mg, about 60 mg, about70 mg, about 80 mg, about 90 mg, about 100 mg, about 110 mg, about 120mg, about 130 mg, about 140 mg, about 150 mg, about 160 mg, about 170mg, about 180 mg, about 190 mg, about 200 mg, about 210 mg, about 220mg, about 230 mg, about 240 mg, about 250 mg, about 260 mg, about 270mg, about 280 mg, about 290 mg, about 300 mg, about 310 mg, about 320mg, about 330 mg, about 340 mg, about 350 mg, about 360 mg, about 370mg, about 380 mg, about 390 mg, about 400 mg, about 410 mg, about 420mg, about 430 mg, about 440 mg, about 450 mg, about 460 mg, about 470mg, about 480 mg, about 490 mg, about 500 mg, about 510 mg, about 520mg, about 530 mg, about 540 mg, about 550 mg, about 560 mg, about 570mg, about 580 mg, about 590 mg, or about 600 mg, of the modifiedangiopoietin.

The amount of the modified angiopoietin contained within the individualdoses may be expressed in terms of milligrams of protein per kilogram ofthe subject's body weight (i.e., mg/kg). For example, the modifiedangiopoietin may be administered to a subject at a dose of about 0.0001to about 100 mg/kg of patient body weight. In certain embodiments, themodified angiopoietin is administered to a subject in need thereof at adose of about 5-25 mg/kg of the subject's body weight.

EXAMPLES

The following examples are put forth so as to provide those of ordinaryskill in the art with a complete disclosure and description of how tomake and use the methods and compositions of the invention, and are notintended to limit the scope of what the inventors regard as theirinvention. Efforts have been made to ensure accuracy with respect tonumbers used (e.g., amounts, temperature, etc.) but some experimentalerrors and deviations should be accounted for. Unless indicatedotherwise, parts are parts by weight, molecular weight is averagemolecular weight, temperature is in degrees Centigrade, and pressure isat or near atmospheric.

Example 1: Alterations in Endothelial Regulators in the MurinePlasmodium berghei ANKA (Pba)-Induced Model of Experimental CerebralMalaria (ECM)

In this Example, the alterations in endothelial regulators in Plasmodiumberghei ANKA (PbA)-induced experimental cerebral malaria in a mousemodel were studied. This model is based on the observation that C57Bl/6mice are susceptible to the murine parasite P. berghei ANKA whichproduces a severe, ultimately fatal disease with neurological symptomsparalleling the symptoms and disease development of cerebral malaria inhumans infected with Plasmodium falciparum. In contrast to C57Bl/6 mice,BALB/c mice are resistant to PbA, in that they do not developencephalopathy, although they become infected and achieve similar orsometimes higher levels of parasite density. This study showed thatdysregulation of the Ang/Tie2 axis was associated with disease severityand fatality. Further, Ang1 levels inversely correlated with morbidityand mortality in the mouse model of cerebral malaria.

Materials and Methods PbA-Induced ECM Model: Infection

Cryopreserved Plasmodium berghei ANKA (PbA; MR4, Manassas, Va.) waspassaged through naïve C57Bl/6 mice. For the experiment, infection wasinitiated in C57Bl/6 and BALB/c mice by intraperitoneal (ip) injectionof 1×10⁶ freshly-isolated parasitized erythrocytes (PE) obtained fromdonor passage mice. Parasitemia was monitored by thin-blood smearstained with modified Geimsa stain (Protocol Hema3 Stain Set, Sigma,Oakville, ON) by counting at least 1500 erythrocytes. The infected micewere monitored for survival, neurological impairment, vascular leakage,parasite burden, and levels of angiogenic factors and markers ofendothelial activation.

Survival and Assessment of Health Status

Post-infection survival of mice was plotted as Kaplan Meier curves usinga log rank test for comparison. Quantitative assessment ofECM-associated neurological impairment (impaired coordination and motorperformance) was performed daily using the 10 parameter Rapid MurineComa and Behavioral Score (RMCBS), as previously described by Carroll RW, et al. 2010 in PLoS ONE 5: e13124. Signs of ECM include impairedbalance/coordination, motor impairment (ataxia, hemiplegia/paraplegia),loss of reflexes and self-preservation, lack of hygiene-related behavior(grooming) and/or fitting. For each parameter, a score was assigned from0 to 2, with 0 indicating the lowest function and a score of 2 thehighest. Total scores for each mouse were calculated and provided as apercentage of the total possible score. Mice with a score of 35% or lesswere deemed to have severe ECM.

Evans Blue Permeability Assay

Vascular permeability in the brain was assessed using Evans blue (EB)dye. Mice were intravenously injected via tail vein with 0.1 mL of 1%Evans blue dye solution (Evans Blue powder; Sigma-Aldrich in PBS, filtersterilized) when clinical signs of ECM were observed. Mice wereeuthanized with isoflurane (99.9% inhalational anesthetic) after 1 hour,perfused with 50 mL of PBS (1×). Brains were dissected aseptically,weighed, photographed and placed in 1 mL N, N-dimethylformamide for 48hours at room temperature to extract dye from tissue. Absorbance wasmeasured at 620 nm. The concentration was calculated using a standardcurve of EB dye and expressed as ng dye per gram of brain tissue.

Detection of Cytokine Markers of Endothelial Activation

Peripheral whole blood was collected by saphenous venipuncture on day 0(d 0; prior to PbA infection) and d 6 p.i. into heparinized tubes(Starstedt). Plasma was isolated from whole blood samples bycentrifugation at 1000×g for 15 min. Plasma samples were aliquoted andstored at −80° C. until analyzed. Levels of mouse intercellular adhesionmolecule-1 (sICAM-1/CD54), E-Selectin (sE-Sel/CD62E) and Vascular CellAdhesion Molecule-1 (sVCAM-1/CD106) in their soluble forms weredetermined in plasma using commercially available murine ELISA kits (R&DSystems, Minneapolis, USA), according to the manufacturers protocol.Levels of von Willebrand Factor antigen (vWF:Ag) was measured in serumby ELISA as follows: 96-well MaxiSorp plates (Nunc) were coatedovernight at 4° C. with a polyclonal antibody anti-human vWF (1:600,Dako, Glostrup, Denmark) in 0.01M PBS. Mouse serum was plated in 1%BSA-PBS and bound vWF:Ag was detected with horseradish peroxidase(HRP)-conjugated polyclonal antibody anti-human vWF (1:8000, Dako).Plates were developed with a 3,3′,5,5′-tetramethylbenzidine (TMB)substrate solution and the absorbance was read at 450 nm, after thecolorimetric reaction was stopped with H₂SO₄. vWF:Ag concentration wasinterpolated from a standard curve created with human vWF of a knownconcentration from fresh frozen plasma (1:500, American Diagnostica,Stamford, Conn.) that was included on each plate. IFN-gamma andTNF-alpha were determined in plasma using commercially available murineELISA kits (eBioscience), according to the manufacturer's protocol.

Statistical Analysis

Statistical analysis was performed using GraphPad Prism version 4.00(San Diego, Calif.). Post-infection survival of mice was plotted asKaplan Meier curves and assessed using log-rank test. Survival studieswere conducted in triplicate and data pooled unless otherwise specified.Shapiro-Wilk test was used to determine normally distributed data andcomparisons between groups were assessed using the non-parametricMann-Whitney test or Kruskal-Wallis test followed by Dunn's post-hoc.Two-way ANOVA was used to compare between groups over multipletime-points. For plasma biomarker testing, the Friedman test with Dunn'smultiple comparison was used to compare levels between samples collectedfrom patients at different time points (e.g., admission andconvalescence). All data are presented as median and IQR(non-parametric), unless otherwise stated. Normally distributed data ispresented as mean and SEM. A p<0.05 was considered statisticallysignificant. Data from multiple experiments were normalized to thegeometric mean of the infected but untreated group of each experimentfor comparisons.

Results

As shown in FIG. 1, the resistant BALB/c mice (also referred to as“ECM-R”) showed significantly prolonged survival (p=0.0007, log ranktest) following infection with PbA as compared to the susceptibleC57Bl/6 mice (also referred to as “ECM-S”). The resistant BALB/c miceshowed 100% survival for 7 days post infection with survival dropping tomore than 10% by Day 10 and up to Day 14 (when the mice weresacrificed). In contrast, the susceptible C57Bl/6 mice showed only about50% survival as early as Day 6 with 0% by Day 8 post infection.

The ECM-S mice showed neurological impairment as evidenced by scoresless than 35% around Day 6 as compared to the resistant ECM-R mice whichshowed an absence of neurological impairment (FIG. 2). Evans Blue (EB)extravasation was used to assess vascular permeability andblood-brain-barrier dysfunction. Following perfusion to removecirculating dye, extravasated EB level in brain parenchyma ofPbA-infected ECM-S mice was 2-fold higher than level in ECM-R mice withcomparable parasite burdens [mean (SD) EB dye/g tissue: 10.7 (7.9) forECM-R mice vs. 22.9 (7.2) for ECM-S mice; p=0.005], consistent withincreased vascular leakage and loss of blood-brain-barrier integrity(FIG. 3). This was independent of observed parasitemia as evidenced by agreater parasite burden in the resistant mice as compared to thesusceptible mice (FIG. 4).

The ECM-R mice differed from the ECM-S mice in the levels of angiogenicfactors Ang1, Ang2 and vWF upon PbA infection. Longitudinal evaluationover the course of infection showed that Ang1 levels decreased with time(p<0.0001, 2-way ANOVA; FIG. 5). The kinetics of Ang1 decline followinginfection was significantly different in ECM-R vs. ECM-S mice (p=0.02,2-way ANOVA). During the acute phase of disease, ECM-R mice maintainedsignificantly higher Ang1 levels as compared to ECM-S mice (p<0.001).For both strains, the loss of circulating Ang1 was associated with theonset of neurological impairment and ECM as determined by a significantdecline in the RMCBS. Ang1 serum levels (ng/ml) correlated significantlywith RMCBS (%) scores (p<0.05; FIG. 6a ) and with time to death (hours)(p<0.0001; FIG. 6b ). Overall, when assessed on day 6 post-infection,mice with lowest levels of circulating Ang1 were significantly morelikely to proceed to a fatal outcome, supporting the hypothesis thatAng1 may be a critical determinant of survival.

The ECM-R mice showed significantly lower Ang2 and vWF levels (FIGS.7-9).

Example 2: Blocking Ang2 does not Confer Improved Protection Against theDevelopment of Experimental CM

In this Example, the effect of Ang2 blockade on PbA-induced ECM in amouse model was assessed. Twenty C57Bl/6 mice were infected byPlasmodium berghei ANKA (PbA) via an intraperitoneal injection of 1×10⁶freshly-isolated parasitized erythrocytes (PE) obtained from donorpassage mice on Day 0. The infected mice were treated with 15 mg/kg ofan anti-Ang2 antibody, H1H685, as described in US Patent ApplicationPublication No. US20110027286, on Days −1, 1, 4, and 7 post-infectionvia subcutaneous injection. The mice were monitored for survival,neurological impairment, parasite burden and plasma protein levels, asdescribed in detail in Example 1.

FIG. 10 shows a Kaplan Meier curve plotting the survival of miceinfected with PbA and treated with anti-Ang2 antibody (referred to as“mAb ‘B’” in FIG. 10), or an isotype control (mAb ‘A’) or saline.Blocking Ang2 with the anti-Ang2 antibody did not lead to increasedsurvival of infected mice as compared to the isotype control. Treatmentwith anti-Ang2 antibody also did not prevent neurological impairment inthe infected mice (FIG. 11), though there was no significant differencein the parasite burden between infected mice treated with anti-Ang2antibody, the isotype control or saline (FIG. 12). The plasma proteinlevels of vWF, ICAM, VCAM and E-selectin did not differ significantly inthe mice treated with the anti-Ang2 antibody, or isotype control (FIG.13).

Example 3: Therapeutic Administration of Ang1 Significantly ImprovesSurvival of Mice Infected with PbA

In this Example, the effect of Ang1 administration on PbA-induced ECM ina mouse model was studied. Eighty C57Bl/6 mice were infected byPlasmodium berghei ANKA (PbA) via an intraperitoneal injection of 1×10⁶freshly-isolated parasitized erythrocytes (PE) obtained from donorpassage mice on Day 0. The infected mice were divided into four groupsand were treated with either 15 mg/kg of an anti-Ang2 antibody (seeExample 2), a “comparator” dual blocking antibody of Ang1/Ang2 or anisotype control, or with 25 mg/kg of AngF1-Fc-F1 (SEQ ID NO: 2) viasubcutaneous injection on Day 4 and Day 6 post infection. The“comparator” dual Ang1/Ang2 blocking antibody was the peptibody 2×Con4C(AMG386) as set forth in U.S. Pat. No. 7,205,275 (Amgen). The mice weremonitored for survival, neurological impairment, parasite burden, andplasma protein levels, as described in detail in Example 1.

As shown in FIG. 14, therapeutic administration of AngF1-Fc-F1 to miceinfected with PbA significantly improved survival (p<0.05, log ranktest) compared to mice treated with the isotype control, anti-Ang2antibody or the dual blocking antibody. The mice treated withAngF1-Fc-F1 showed more than 35% survival up to at least Day 15 p.i. ascompared to the mice treated with the other three treatments whichshowed 0% survival by Day 8 post infection, though the percentparasitemia across all treatments was similar (FIG. 15). The treatmentwith AngF1-Fc-F1 also protected blood brain barrier integrity as shownby Evans Blue dye uptake (FIG. 16). The mice treated with AngF1-Fc-F1showed significantly low amount of dye uptake (panel C of FIG. 16a ),consistent with maintenance of an intact blood brain barrier and reducedvascular permeability (p<0.05, Kruskal-Wallis), even though the percentparasitemia was similar (FIG. 16b ). This confirmed that exogenous Ang1is sufficient to maintain blood-brain-barrier integrity following alethal malaria challenge.

The therapeutic administration of AngF1-Fc-F1 also preventedECM-associated morbidity and neurological impairment (FIG. 17),independent of changes to peripheral parasitemia (FIG. 18). By day 6post-infection, the majority of control mice had progressed to ECM,whereas disease progression was mitigated in treated mice. InfectedAngF1-Fc-F1-treated mice displayed similar weight loss tocontrol-treated mice.

To determine whether vascular protection with AngF1-Fc-F1 occurredsecondary to a reduction in inflammatory cytokines or whether protectionwas due to a direct enhancement of vascular stability in the face of asystemic inflammatory response, plasma samples from treated anduntreated PbA-infected mice were assayed for key pro-inflammatorycytokines. PbA-infected mice showed a significant increase in TNF andIFNγ on day 6 post-infection (3-fold increase in TNF and a 60-foldincrease in IFNγ compared to baseline, p<0.01 for both, one-way ANOVA)despite treatment. Treatment with AngF1-Fc-F1 did not affect levels ofTNF or IFNγ, with both control and treated mice showing a similarup-regulation in response to infection (FIG. 19a ).

Pro-inflammatory cytokine stimulation and/or direct endothelialinteractions with parasitized erythrocytes may contribute to a number ofpathological events implicated in CM, including up-regulation ofendothelial cell receptors that mediate parasite cytoadhesion.Disruption of parasite sequestration to host receptors viadown-regulation of cell adhesion molecules (CAMs), such as ICAM-1 and/orvascular cellular adhesion molecule-1 (VCAM-1), may lessen microvascularobstruction and endothelial dysfunction. Therefore, the effect of Ang1treatment on reduction of circulating levels of soluble forms of CAMS,considered as an indicator of endothelial activation and a pro-adhesivevascular phenotype, was investigated. Analysis of plasma samplescollected on day 6 post-infection showed a 4-fold increase incirculating levels of sICAM-1 with PbA infection, compared to baseline(p<0.001, One-way ANOVA with Bonferroni test for multiple comparisons;FIG. 19c ). These levels were significantly reduced with Ang1 treatmentcompared to PbA-infected controls (p<0.05; FIG. 19c ). Similarly,sVCAM-1 levels significantly increased at day 6 post-infection with PbA(5-fold increase, p<0.001; FIGS. 19c ) and Ang1 treatment significantlyreduced circulating levels of sVCAM-1 compared to PbA-infected controls(p<0.05, FIG. 19c ). These data indicate that Ang-1-Tie-2 interactionshelp to maintain vascular quiescence in the face of systemicinflammatory response, in part through preservation of an anti-adhesivevascular phenotype via down regulation of adhesion molecules.

This study showed that therapeutic administration of Ang1 (AngF1-Fc-F1),but not inhibition of Ang2 improved blood brain barrier integrity andsurvival. It supported investigation of pro-Ang1, but not inhibition ofAng2 as adjunctive therapy for cerebral malaria. Further, it is ofinterest that Ang1-based treatment was efficacious and preserved bloodbrain barrier integrity, despite a robust systemic pro-inflammatoryresponse to infection. The data suggest that anti-inflammatorystrategies may not be required to preserve vascular integrity andimprove outcome in life-threatening infections associated with systemicinflammation.

In one further experiment, AngF1-Fc-F1 will be administered incombination with an anti-Tie2 antibody (as set forth in US20130209492)to infected susceptible C57Bl/6 mice to study the involvement of Tie2 inblocking the protective effect of AngF1-Fc-F1. The anti-Tie2 antibodymay an activating (or agonist) antibody, e.g., it increases the bindingof an angiopoietin and/or increases the activity of Tie2. It is expectedthat AngF1-Fc-F1 administered in combination with anti-Tie2 antibodywill lead to lower survival of infected mice as compared to AngF1-Fc-F1alone.

In another further experiment, AngF1-Fc-F1 will be used to treatresistant BALB/c mice infected with PbA to study the effect on survival,blood brain barrier integrity, neurological impairment, and plasmaprotein markers. It is expected that administration of AngF1-Fc-F1 willlead to improved protection of blood brain barrier integrity andsurvival of infected BALB/c mice.

In a third experiment, AngF1-Fc-F1 will be administered in combinationwith an anti-Tie2 antibody to infected resistant BALB/c mice to study ifthe resistant mice are rendered susceptible to ECM. It is expected thatAngF1-Fc-F1 administered in combination with anti-Tie2 antibody willlead to lower survival of infected BALB/c mice as compared toAngF1-Fc-F1 alone.

Example 4: Therapeutic Administration of AngF1-Fc-F1 as AdjunctiveTherapy in Combination with Artesunate

In this Example, the effect of administration of Ang-F1-Fc-F1 incombination with artesunate on PbA-induced ECM in a mouse model wasstudied. Twenty C57Bl/6 mice were infected by Plasmodium berghei ANKA(PbA) via an intraperitoneal injection of 1×10⁶ freshly-isolatedparasitized erythrocytes (PE) obtained from donor passage mice on Day 0.The infected mice were treated with 15 mg/kg of AngF1-Fc-F1 (SEQ ID NO:2) on Days 4 and 6 post infection and with 10 mg/kg of artesunate on Day5 post-infection via subcutaneous injection. The mice were monitored forsurvival, neurological impairment, parasite burden, and plasma proteinlevels, as described in detail in Example 1.

Adjunctive AngF1-Fc-F1 treatment significantly improved survival ofinfected mice as compared to artesunate alone (FIG. 20). Infected micetreated with AngF1-Fc-F1 in combination with artesunate showed 100%survival at least up to Day 15 post infection. In contrast, infectedmice treated with artesunate alone showed less than 60% survival by Day8 post infection. Despite significantly diminished parasite burden topre-ECM levels (i.e., <2% parasitemia), 41.7% of artesunate treated micedied of ECM. This effect was independent of percent parasitemia (FIG.21).

In a further experiment, the effect of adjunctive AngF1-Fc-F1 incombination with artesunate will be studied on neurological impairmentin infected mice. It is expected that administration of AngF1-Fc-F1 incombination with artesunate will prevent neurological impairment ininfected mice as compared to artesunate alone.

In another further experiment, AngF1-Fc-F1 will be administered incombination with an anti-Ang2 antibody (as described in Example 2) tostudy survival of infected mice. It is expected that AngF1-Fc-F1administered in combination with anti-Ang2 antibody will lead toimproved survival of infected mice as compared to AngF1-Fc-F1 alone.

Example 5: Protection from Malaria-Associated Acute Lung Injury

In this Example, the effect of AngF1-Fc-F1 administration on vascularpermeability in lung and malaria-associated acute lung injury ininfected mice will be studied. Twenty C57Bl/6 mice will be infected withPlasmodium berghei ANKA (PbA) via an intraperitoneal injection of 1×10⁶freshly-isolated parasitized erythrocytes (PE) obtained from donorpassage mice on Day 0. The infected mice will be treated with 15 mg/kgof AngF1-Fc-F1 (SEQ ID NO: 2) on Days 4, and 6 post-infection viasubcutaneous injection. The mice will be monitored for survival andvascular permeability in lung by Evans Blue staining.

It is expected that mice treated with AngF1-Fc-F1 will show absence ofEvans Blue dye uptake in lungs pointing to absence of vascularpermeability and protection from malaria-associated acute lung injury.

The present invention is not to be limited in scope by the specificembodiments described herein. Indeed, various modifications of theinvention in addition to those described herein will become apparent tothose skilled in the art from the foregoing description and theaccompanying figures. Such modifications are intended to fall within thescope of the appended claims.

1-41. (canceled)
 42. A method of increasing survival of a subjectafflicted with a disease or disorder selected from the group consistingof severe cerebral malaria, experimental cerebral malaria, sepsis,dengue, hemorrhagic fever, toxic shock syndrome, hemorrhagic shock,hemolytic uremic syndrome, myocardial infarction and stroke, the methodcomprising administering a pharmaceutical composition comprising atherapeutically effective amount of an exogenous modified angiopoietinprotein to the subject in need thereof.
 43. The method of claim 42,wherein the subject is infected with Plasmodium spp.
 44. The method ofclaim 42, wherein the administration of the modified angiopoietinresults in protection of the blood barrier integrity in the subject. 45.The method of claim 42, wherein the administration of the modifiedangiopoietin results in preventing at least one indication ofneurological impairment in the subject.
 46. The method of claim 45,wherein the at least one indication of neurological impairment isselected from the group consisting of impaired balance or coordination,motor impairment, loss of reflexes and self-preservation, long termneurocognitive injury and impairment, memory deficits, affectivedisorders, lack of hygiene-related behavior, convulsion, and fitting.47. The method of claim 42, wherein the modified angiopoietin isadministered at a dose of 15 mg/kg of the subject's body weight.
 48. Themethod of claim 42, wherein the modified angiopoietin is administeredsubcutaneously.
 49. The method of claim 42, wherein the modifiedangiopoietin is administered in combination with a second therapeuticagent.
 50. The method of claim 49, wherein the second therapeutic agentis artesunate.
 51. The method of claim 42, wherein the modifiedangiopoietin comprises a fusion protein comprising angiopoietin-1 or afragment thereof fused to a multimerizing domain.
 52. The method ofclaim 51, wherein the multimerizing domain is an immunoglobulin Fcfragment.
 53. The method of claim 52, wherein the fusion proteincomprises at least one fibrinogen-like domain of angiopoietin-1 fused toan Fc fragment.
 54. The method of claim 53, wherein the fusion proteincomprises a first fibrinogen-like domain of angiopoietin-1 fused at itsC-terminal end to the N-terminal end of an Fc fragment and the Fcfragment fused at its C-terminal end to the N-terminal end of a secondfibrinogen-like domain of angiopoietin-1.
 55. The method of claim 42,wherein the modified angiopoietin is AngF1-Fc-F1.
 56. The method ofclaim 42, wherein the modified angiopoietin comprises an amino acidsequence of SEQ ID NO: 2.